The effects of a disease management program on self-reported health behaviors and health outcomes: evidence from the "Florida: a healthy state (FAHS)" Medicaid program

Positive change in asthma control using therapeutic patient education in severe uncontrolled asthma: a one-year prospective study

Background

Severe asthma is difficult to control. Therapeutic patient education enables patients to better understand their disease and cope with treatment, but the effect of therapeutic patient education in severe uncontrolled asthma is unclear. We evaluated whether therapeutic patient education is effective in improving asthma control and decreasing the frequency of exacerbations in severe uncontrolled asthma.

Methods

This was a prospective, observational, and self-controlled study that enrolled 40 subjects with severe uncontrolled asthma. Patients were seen at a clinic four times (on day 1 and after 3, 6, and 12 months). After baseline data collection, the subjects completed a therapeutic patient education program and were also followed-up via telephone after 1, 2, 4, 5, 7, 8, 9, 10, and 11 months to monitor asthma medication adherence and collect asthma-related information.

Results

Within the 1-year study period, a total of 23 exacerbations were recorded in 14 patients, seven of whom required emergency treatment and two of whom were hospitalized. Twelve months after the standardized therapeutic patient education program, pulmonary function and fractional exhaled nitric oxide levels improved significantly in all 40 patients. Moreover, the scores from three standardized asthma questionnaires and indices suggested improved quality of life in these patients with severe uncontrolled asthma. Serum levels of biomarkers reflecting asthma immune responses did not change between baseline and the 1-year follow-up time point.

Conclusions

Therapeutic patient education is effective in improving asthma control and decreasing exacerbations in patients with severe uncontrolled asthma.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40733-021-00076-y.

"It all needs to be a full jigsaw, not just bits": exploration of healthcare professionals' beliefs towards supported self-management for long-term conditions

BACKGROUND

Long-Term Conditions are physical health issues which profoundly impact physical and psychological outcomes and have reached epidemic worldwide levels. An increasing evidence-base has developed for utilizing Supported Self-Management to ensure Health, Social Care & Voluntary staff are knowledgeable, skilled, and experienced to enable patients to have the confidence and capability to self-manage their conditions. However, despite Health Psychology theories underpinning chronic care models demonstrating beliefs are crucially associated with intention and behaviour, staff beliefs towards Supported Self-Management have received little attention. Therefore, the study aimed to explore healthcare professionals' beliefs towards Supported Self-Management for Long-Term Conditions using the Theory of Planned Behaviour.

METHODS

A mixed-methods approach was conducted within a single UK local government authority region in 2 phases: (1) Qualitative focus group of existing Supported Self-Management project staff (N = 6); (2) Quantitative online questionnaire of general Long-Term Conditions staff (N = 58).

RESULTS

(1) Eighty two utterances over 20 theme sub-codes demonstrated beliefs that Supported Self-Management improves healthcare outcomes, but requires enhancements to patient and senior stakeholder buy-in, healthcare culture-specific tailoring, and organizational policy and resources; (2) Mean scores indicated moderate-strength beliefs that Supported Self-Management achieves positive healthcare outcomes, but weak-strength intentions to implement Supported Self-Management and beliefs it is socially normative and perceived control over implementing it. Crucially, regression analyses demonstrated intentions to implement Supported Self-Management were only associated with beliefs that important others supported it and perceived control over, or by whether it was socially encouraged.

CONCLUSIONS

Healthcare professionals demonstrated positive attitudes towards Supported Self-Management improving healthcare outcomes. However, intentions towards implementing this approach were low with staff only slightly believing important others (including patients and clinicians) supported it and that they had control over using it. Future Supported Self-Management projects should seek to enhance intention (and consequently behaviour) through targeting beliefs that important others do indeed actually support this approach and that staff have control over implementing it, as well as enhancing social encouragement.

Adherence to treatment in allergic respiratory diseases

Introduction: Asthma and allergic rhinitis (AR) are chronic conditions in which management needs adherence to prescribed drugs. Despite the benefits of regular maintenance of asthma and AR therapy, low adherence is a frequent issue in clinical practice. Areas covered: The aim of this review is to provide a targeted analysis of the more recent literature on adherence in asthma and AR, focused on the following areas: adherence extent, barriers and consequences, effects of educational interventions and use of new technologies to improve the level of adherence. Expert commentary: Despite the extent, reasons and effects of this problem being well known, non-adherence in asthma and allergic AR remains worryingly high. Poor adherence leads to unsatisfactory health outcomes, with a negative impact on patients and society. Recent literature suggests that successful programs to improve adherence should include a combination of strategies. The new technologies represent a promising tool to improve adherence.

Adherence to medication in children and adolescents with asthma: methods for monitoring and intervention

INTRODUCTION

Poor adherence in children with asthma is a major cause of asthma attacks and poor control, leads to large health-care costs, and has been identified as a factor in asthma deaths. However, it is difficult to detect and frequently overlooked leading to inappropriate escalation of asthma treatment. There is a need for cost effective ways to monitor adherence in order to intervene to change this modifiable behavior. Areas covered: Several measurement tools have been developed to assess adherence in adults and children with asthma. The current methods for measuring adherence, both subjective and objective, have several flaws and even the current gold standard, electronic monitoring devices (EMDs), has limitations. This review will outline and critique the adherence monitoring tools and highlight ways in which they have been used for the purpose of intervention. Expert commentary: Although advances have been made in adherence monitoring, we still have some way to go in creating the ideal monitoring tool. There are no validated tailored self-monitoring questionnaires for children with asthma and most objective measures, such as prescription refill rate and weighing canisters, overestimate adherence. Current EMDs, although useful, need improved accuracy to ensure that both actuation and inhalation are measured, and the devices need to be affordable for use in routine health-care practice.

Frequency of asthma education in primary care in the years 2007-2010

OBJECTIVE

Recent research suggests that health disparities persist among asthmatic patients and receipt of asthma education, though recent guidelines have highlighted the importance of receiving asthma education. The purpose of this study was to identify trends in the receipt of asthma education as well as to identify disparities in asthma education using the most recently available data in National Ambulatory Medical Care Survey, 2007-2010.

METHODS

Weighted chi-square tests were conducted to identify associations between asthma education and variables of interest. A weighted multivariate logistic regression model was subsequently constructed to jointly assess the association of factors of interest on receipt of asthma education. Submission to the Campbell University Institutional Review Board resulted in expedited approval.

RESULTS

The percentage of patients who receive asthma education remains quite low. After adjusting for all variables of interest: no statistically significant difference in receipt of asthma education between year groups (2007-2008, 2009-2010) was found (odds ratio [OR] 0.84, 95% confidence interval [CI] 0.52-1.34); patients seen by pediatricians (vs. internal medicine physicians) and Hispanic or Latino patients (vs. non-Hispanic or Latino patients) were more likely to receive asthma education (OR 2.72, 95% CI 1.11-6.66 and OR 2.33, 95% CI 1.18-4.60, respectively); and patients not prescribed a controller medication were less likely to receive asthma education than those who were (OR 0.56, 95% CI 0.37-0.82).

CONCLUSIONS

Combined with previously published results, it appears the provision of asthma education continues to be low, despite proven benefits. Additionally, some patient and physician characteristics may be associated with the delivery of asthma education.

Adherence to asthma treatments: 'we know, we intend, we advocate'

PURPOSE OF REVIEW

To highlight the state of the art and the current outlook on the adherence to treatment in asthma, starting from the 'Manifesto on Adherence to asthma treatment in respiratory allergy' endorsed by the World Allergy Organization, Allergic Rhinitis and Its Impact on Asthma and Global Allergy, Asthma European Network, and Interasma.

RECENT FINDINGS

Adherence to the pharmacological treatments of asthma is known to be low: about 50% of those who had been prescribed long-term treatment are nonadherent, at least part of the time. Nonadherence is associated with lack of asthma control, poor health outcomes, and increased costs. The reasons for suboptimal adherence are multifaceted and may be related to the patients, the treatment and asthma features, the physician-patient relationship, and the healthcare resources and facilities.

SUMMARY

Taking into account the multidimensional nature of adherence, no single intervention or strategy is per se able to enhance it, but all players involved in the process (government authorities, patient organizations, scientific societies, stakeholders, and others) are called to work together to develop a combined action plan based on the patient's complexity.

Chronic disease management programmes for adults with asthma

BACKGROUND

The burden of asthma on patients and healthcare systems is substantial. Interventions have been developed to overcome difficulties in asthma management. These include chronic disease management programmes, which are more than simple patient education, encompassing a set of coherent interventions that centre on the patients' needs, encouraging the co-ordination and integration of health services provided by a variety of healthcare professionals, and emphasising patient self-management as well as patient education.

OBJECTIVES

To evaluate the effectiveness of chronic disease management programmes for adults with asthma.

SEARCH METHODS

Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, MEDLINE (MEDLINE In-Process and Other Non-Indexed Citations), EMBASE, CINAHL, and PsycINFO were searched up to June 2014. We also handsearched selected journals from 2000 to 2012 and scanned reference lists of relevant reviews.

SELECTION CRITERIA

We included individual or cluster-randomised controlled trials, non-randomised controlled trials, and controlled before-after studies comparing chronic disease management programmes with usual care in adults over 16 years of age with a diagnosis of asthma. The chronic disease management programmes had to satisfy at least the following five criteria: an organisational component targeting patients; an organisational component targeting healthcare professionals or the healthcare system, or both; patient education or self-management support, or both; active involvement of two or more healthcare professionals in patient care; a minimum duration of three months.

DATA COLLECTION AND ANALYSIS

After an initial screen of the titles, two review authors working independently assessed the studies for eligibility and study quality; they also extracted the data. We contacted authors to obtain missing information and additional data, where necessary. We pooled results using the random-effects model and reported the pooled mean or standardised mean differences (SMDs).

MAIN RESULTS

A total of 20 studies including 81,746 patients (median 129.5) were included in this review, with a follow-up ranging from 3 to more than 12 months. Patients' mean age was 42.5 years, 60% were female, and their asthma was mostly rated as moderate to severe. Overall the studies were of moderate to low methodological quality, because of limitations in their design and the wide confidence intervals for certain results.Compared with usual care, chronic disease management programmes resulted in improvements in asthma-specific quality of life (SMD 0.22, 95% confidence interval (CI) 0.08 to 0.37), asthma severity scores (SMD 0.18, 95% CI 0.05 to 0.30), and lung function tests (SMD 0.19, 95% CI 0.09 to 0.30). The data for improvement in self-efficacy scores were inconclusive (SMD 0.51, 95% CI -0.08 to 1.11). Results on hospitalisations and emergency department or unscheduled visits could not be combined in a meta-analysis because the data were too heterogeneous; results from the individual studies were inconclusive overall. Only a few studies reported results on asthma exacerbations, days off work or school, use of an action plan, and patient satisfaction. Meta-analyses could not be performed for these outcomes.

AUTHORS' CONCLUSIONS

There is moderate to low quality evidence that chronic disease management programmes for adults with asthma can improve asthma-specific quality of life, asthma severity, and lung function tests. Overall, these results provide encouraging evidence of the potential effectiveness of these programmes in adults with asthma when compared with usual care. However, the optimal composition of asthma chronic disease management programmes and their added value, compared with education or self-management alone that is usually offered to patients with asthma, need further investigation.

Effect of Medicaid disease management programs on emergency admissions and inpatient costs

OBJECTIVE

To determine the impact of state Medicaid diabetes disease management programs on emergency admissions and inpatient costs.

DATA

National InPatient Sample sponsored by the Agency for Healthcare Research and Quality Project for the years from 2000 to 2008 using 18 states.

STUDY DESIGN

A difference-in-difference methodology compares costs and number of emergency admissions for Washington, Texas, and Georgia, which implemented disease management programs between 2000 and 2008, to states that did not undergo the transition to managed care (N = 103).

DATA EXTRACTION

Costs and emergency admissions were extracted for diabetic Medicaid enrollees diagnosed in the reform and non-reform states and collapsed into state and year cells.

PRINCIPAL FINDINGS

In the three treatment states, the implementation of disease management programs did not have statistically significant impacts on the outcome variables when compared to the control states.

CONCLUSIONS

States that implemented disease management programs did not achieve improvements in costs or the number of emergency of admissions; thus, these programs do not appear to be an effective way to reduce the burden of this chronic disease.

A systematic review of patient self-reported barriers of adherence to antihypertensive medications using the world health organization multidimensional adherence model

Multiple barriers can influence adherence to antihypertensive medications. The aim of this systematic review was to determine what adherence barriers were included in each instrument and to describe the psychometric properties of the identified surveys. Barriers were characterized using the World Health Organization (WHO) Multidimensional Adherence Model with patient, condition, therapy, socioeconomic, and health care system/team-related barriers. Five databases (Medline, Embase, Health and Psychological Instruments, CINHAL, and International Pharmaceutical Abstracts [IPA]) were searched from 1980 to September 2011. Our search identified 1712 citations; 74 articles met inclusion criteria and 51 unique surveys were identified. The Morisky Medication Adherence Scale was the most commonly used survey. Only 20 surveys (39%) have established reliability and validity evidence. According to the WHO Adherence Model domains, patient-related barriers were most commonly addressed, while condition, therapy, and socioeconomic barriers were underrepresented. The complexity of adherence behavior requires robust self-report measurements and the inclusion of barriers relevant to each unique patient population and intervention.

Recent educational interventions for improvement of asthma medication adherence

Poor adherence to asthma medication treatment is a dilemma as it decreases the chance of achieving and maintaining a proper asthma control. Another dilemma is that there seems to be a small range of functional interventions that enhance adherence to long-term medication treatments. The aim was to review the last five years of published educational interventions for improving adherence to asthma medication. Through systematic database searches 20 articles were identified, which matched the inclusion criteria and described educational interventions to improve asthma self-management including adherence. The current review showed that addressing unintentional non-adherence in terms of incorrect inhaler technique by recurrent education improved the technique among many patients, but not among all. Phoning patients, as a means to remove medication beliefs as adherence barriers, seemed to be an effective educational strategy, shown as increased adherence. Involving patients in treatment decisions and individualising or tailoring educational support also seemed to have favourable effect on adherence. To conclude, addressing specific adherence barriers such as poor inhaler technique or medication beliefs could favour adherence. To change adherence behavior, the current review proposes that educational adherence support should be a collaborative effort between the patient and the health-care professional based on each individual patient's needs and patient factors, including elements such as personality traits.

Prospective analysis of LDL-C goal achievement and self-reported medication adherence among statin users in primary care

BACKGROUND

Improvements in the control of LDL-C levels have occurred in the past decade due to the introduction of increasingly potent statins, such as atorvastatin and rosuvastatin. Many patients, however, do not achieve their LDL-C goals, which presents a practical dilemma for clinicians and highlights the need to identify adherence problems in a clinically relevant manner.

OBJECTIVE

The purpose of this study was to evaluate the relationship between LDL-C goal achievement and both medication adherence and beliefs assessed using structured questioning.

METHODS

All patients were aged ≥40 years and participated in the cardiovascular risk factor management program STOP-HF (St. Vincent's Screening To Prevent Heart Failure study). One hundred and eighty-five participants who had been prescribed statins, split between those who achieved and those who did not achieve LDL-C goal, were randomly selected for a prospective study examining the relationship between adherence, assessed by the Morisky Medication Adherence Scale (MMAS), and LDL-C goal achievement. Patients' beliefs about medicines were assessed using the Beliefs about Medicines Questionnaire-General (BMQ-G). Main outcome measures were predictors of LDL-C goal achievement and medication adherence and predictors of adherence among patients using the MMAS.

RESULTS

The average age of the selected patients was 64.9 (9.9) years; 45% were male, 46% had hypertension, 17.5% had coronary artery disease, and 10% had diabetes. Questionnaires were answered by 119 patients, 71 of whom (59.7%) were goal achievers. LDL-C goal achievers were more likely to respond to the questionnaires than nonachievers (76.8% vs 52.7%; P = 0.002). Fifty-eight respondents (48.7%) reported that they were not fully adherent to medication and in multivariable analysis were twice as likely to miss LDL-C goal compared with those who were adherent. Approximately 25% of patients who reported nonadherence were intentionally so. Patients' beliefs about medicines were a significant predictor of self-reported adherence but not of LDL-C goal achievement.

CONCLUSIONS

Medication nonadherence may be responsible for failure to achieve goal in many patients who are prescribed statins. In routine clinical care, the structured MMAS questionnaire may provide clinicians with an effective tool to assess medication nonadherence in the context of statin therapy failure. STOP-HF ClinicalTrials.gov identifier: NCT00921960.

Economic impact of a Medicaid population health management program

A population health management program was implemented to assess growth in health care expenditures for the disabled segment of Georgia's Medicaid population before and during the first year of a population health outcomes management program, and to compare those expenditures with projected costs based on various cost inflation trend assumptions. A retrospective, nonexperimental approach was used to analyze claims data from Georgia Medicaid claims files for all program-eligible persons for each relevant time period (intent-to-treat basis). These included all non-Medicare, noninstitutionalized Medicaid aged-blind-disabled adults older than 18 years of age. Comparisons of health care expenditures and utilization were made between base year (2003-2004) and performance year one (2006-2007), and of the difference between actual expenditures incurred in the performance year vs. projected expenditures based on various cost inflation assumptions. Demographic characteristics and clinical complexity of the population (as measured by the Chronic Illness and Disability Payment System risk score) actually increased from baseline to implementation. Actual expenditures were less than projected expenditures using any relevant medical inflation assumption. Actual expenditures were less than projected expenditures by $9.82 million when using a conservative US general medical inflation rate, by $43.6 million using national Medicaid cost trends, and by $106 million using Georgia Medicaid's own cost projections for the non-dually eligible disabled segment of Medicaid enrollees. Quadratic growth curve modeling also demonstrated a lower rate of increase in total expenditures. The rate of increase in expenditures was lower over the first year of program implementation compared with baseline. Weighted utilization rates were also lower in high-cost categories, such as inpatient days, despite increases in the risk profile of the population. Varying levels of cost avoidance could be inferred from differences between actual and projected expenditures using each of the health-related inflation assumptions.

Does the pharmacy expenditure of patients always correspond with their morbidity burden? Exploring new approaches in the interpretation of pharmacy expenditure

Background

The computerisation of primary health care (PHC) records offers the opportunity to focus on pharmacy expenditure from the perspective of the morbidity of individuals. The objective of the present study was to analyse the behaviour of pharmacy expenditure within different morbidity groups. We paid special attention to the identification of individuals who had higher values of pharmacy expenditure than their morbidity would otherwise suggest (i.e. outliers).

Methods

Observational study consisting of 75,574 patients seen at PHC centres in Zaragoza, Spain, at least once in 2005. Demographic and disease variables were analysed (ACG^® 8.1), together with a response variable that we termed 'total pharmacy expenditure per patient'. Outlier patients were identified based on boxplot methods, adjusted boxplot for asymmetric distributions, and by analysing standardised residuals of tobit regression models.

Results

The pharmacy expenditure of up to 7% of attendees in the studied PHC centres during one year exceeded expectations given their morbidity burden. This group of patients was responsible for up to 24% of the total annual pharmacy expenditure. There was a significantly higher number of outlier patients within the low-morbidity band which matched up with the higher variation coefficient observed in this group (3.2 vs. 2.0 and 1.3 in the moderate- and high-morbidity bands, respectively).

Conclusions

With appropriate validation, the methodologies of the present study could be incorporated in the routine monitoring of the prescribing profile of general practitioners. This could not only enable evaluation of their performance, but also target groups of outlier patients and foster analyses of the causes of unusually high pharmacy expenditures among them. This interpretation of pharmacy expenditure gives new clues for the efficiency in utilisation of healthcare resources, and could be complementary to management interventions focused on individuals with a high morbidity burden.

Applying diagnosis and pharmacy-based risk models to predict pharmacy use in Aragon, Spain: the impact of a local calibration

Background

In the financing of a national health system, where pharmaceutical spending is one of the main cost containment targets, predicting pharmacy costs for individuals and populations is essential for budget planning and care management. Although most efforts have focused on risk adjustment applying diagnostic data, the reliability of this information source has been questioned in the primary care setting. We sought to assess the usefulness of incorporating pharmacy data into claims-based predictive models (PMs). Developed primarily for the U.S. health care setting, a secondary objective was to evaluate the benefit of a local calibration in order to adapt the PMs to the Spanish health care system.

Methods

The population was drawn from patients within the primary care setting of Aragon, Spain (n = 84,152). Diagnostic, medication and prior cost data were used to develop PMs based on the Johns Hopkins ACG methodology. Model performance was assessed through r-squared statistics and predictive ratios. The capacity to identify future high-cost patients was examined through c-statistic, sensitivity and specificity parameters.

Results

The PMs based on pharmacy data had a higher capacity to predict future pharmacy expenses and to identify potential high-cost patients than the models based on diagnostic data alone and a capacity almost as high as that of the combined diagnosis-pharmacy-based PM. PMs provided considerably better predictions when calibrated to Spanish data.

Conclusion

Understandably, pharmacy spending is more predictable using pharmacy-based risk markers compared with diagnosis-based risk markers. Pharmacy-based PMs can assist plan administrators and medical directors in planning the health budget and identifying high-cost-risk patients amenable to care management programs.

Relationships among self-management, patient perceptions of care, and health economic outcomes for decision-making and clinical practice in type 2 diabetes

OBJECTIVES

Type 2 diabetes (T2D) treatment involves complex interactions between biological, psychological, and behavioral factors of care, requiring multifaceted efforts in clinical practice and disease management to reduce health and economic burdens. We aimed to quantify correlations among these factors and characterize their level of inclusion in economic analyses that are part of informed medical decision-making.

METHODS

A comprehensive, stepwise systematic literature review was performed on published articles dated 1993 to 2008 using medical subject heading and keyword searches in electronic reference libraries. Data were collected using standardized techniques and were analyzed descriptively.

RESULTS

A total of 97 articles fulfilling all inclusion criteria were reviewed, including 16 on economic models (17% of articles). Most studies were retrospective (41 of 97; 42%) and from managed care perspectives (66%). Oral antidiabetic drugs were a central focus, appearing in 83% of studies. Patient behaviors, particularly medication adherence and persistence in real-world settings, are well researched (n=65) and may influence diabetes outcomes, cardiovascular risk, mortality rates, and treatment-specific resource use (e.g., hospitalizations) and costs (<or=$3400 annually per patient). Nevertheless, they are absent from current economic models.

CONCLUSIONS

Strong correlations exist between patient behaviors, perspectives of care, health outcomes, and costs in T2D. Enhancing their inclusion in pharmacoeconomic modeling, notably the influence on clinical effectiveness of variation in self-management between treatments, should ultimately lead to more accurate estimates of comparative cost-effectiveness, and thereby improve value-based resource allocation and patient access to appropriate therapy.